Introduction. Chronic ruptures of the Achilles tendon pose a significant management challenge to the clinician. Numerous methods of surgical reconstruction have been described and are generally associated with a higher complication rate than with immediate repair. We report our results with a single 5cm incision technique to reconstruct chronic Achilles tendon ruptures with transfer of FHL. This simple technique also enables easy tensioning of the graft/reconstruction to match the uninjured leg and early mobilisation. Materials & Methods. All patients undergoing late Achilles tendon reconstruction (over 4 months from rupture) during the period September 2006 to January 2010 were included in the study. All patients were treated using a single incision technique and posterior ankle FHL harvest with bio absorbable interference screw fixation in the calcaneum. Weight bearing was allowed from 2 weeks post operatively with a dynamic rehabilitation regime identical to that which we use following repair of acute ruptures. A retrospective review of the records was performed and a further telephone review undertaken. Results. 15 ‘late’ Achilles tendon reconstructions were undertaken in the study period. Their mean age was 55 years (38-80). Mean time from rupture was 16 months (5-96). Significant co-morbities included diabetes, chronic renal failure, multiple schlerosis and Parkinson's disease. The mean duration of follow-up was 20 months (7–38). There were no post-operative complications. AOFAS score improved significantly in all patients and all reported good or excellent improvement in strength and return to pre-injury function (including sport in 2 cases). Conclusion. This less invasive single incision technique of FHL transfer reconstruction of chronic Achilles tendon ruptures as previously published from our unit seems to be a safe and reliable undertaking in patients with symptomatic chronic Achilles ruptures and is our preferred technique for all chronic ruptures especially in the presence of significant co-morbities

PURPOSE: We describe the results of 64 patients who underwent treatment for acute distal biceps tendon rupture using a single incision and suture anchors. The purpose of the study is to evaluate if this method is reliable and if it can reduse the risk of ectopic bone formation or synostosis. Methods: 64 patients underwent surgical repair for acute rupture of the distal biceps tendon, using suture anchors and a single incision. All performed by 1 surgeon. We had 63 male and 1 female with a mean age of 48 years (range 30–59). Our operative technique consisted of an “S”-shaped anterior incision centered over the antecubital fossa. After identification and protection of the lateral antebrachial cutaneous nerve, we exposed and mobilized the ruptured biceps tendon. The distal portion of the tendon was debrided and the radial tuberosity gently decorticated. A 4 stranded suture was then inserted into the tuberosity. The tendon was advanced to bone and the sutures were tied using the modification of Kessler’s technique, holding the elbow in 90° of flexion. The post-op protocol was a posterior splint for 10 days (in 90° of flexion and 20° of supination), a dynamic hinged-extension block brace in 45° for 3 weeks and progressive advancement to full extension in 3 more weeks. Strengthening exercises were permitted after 3 months. Results: All acute tears (< 3 weeks) were repaired anatomically. The follow-up period was 39 months (range 18m – 11years). Objective data consisted of ROM (range of motion) of the elbow, flexion and supination strength were measured by a BTE Work Stimulator. The ROM was normal in 54 patients, 10 patients lacked 10° of extension. 51 patients returned to their pre-injury level of activity and within 6 months returned to work. All patients reported pain relief and good recovery of strength and were completely satisfied of the outcome. There were no implant failures, nerve palsies or heterotopic bone formation. Conclusions: Use of a single incision repair with bone suture anchors provides secure fixation of distal biceps tendon to the radius with minimal volar dissection wich is associated with a minimum risk of synostosis and posterior interosseous nerve injuries. This method is reliable for acute ruptures. Return to normal strength and range of motion can be expected if tendon repair is performed before 3 weeks. The advantages of this method are less dissection for re-attachment of the tendon, less nerve injuries and no ectopic bone formation or synostosis

Introduction: In a prospective clinical study the feasibility of total hip arthroplasty via a minimal invasive single incision anterior approach was analyzed. 100 consecutive patients with no exclusion criteria (52 females, 48 males, mean age 65.6 yrs) were included. 19 patients showed a BMI > 30. Material and Methods: The patients were placed in a supine position on the OR table. After skin incision the interval between sartorius, tensor fasciae latae, rectus femoris and glutaeus medius/minimus was split to bluntly expose the anterior aspect of the hip joint capsule. No muscle had to be dissected. Following capsular incision the neck was osteotomized in-situ. After reaming a cemented or cement-less cup was inserted. The calcar was elevated with a hook to the level of skin incision. By placing special two-pronged retractor between the inserting abductor tendons and the greater trochanter the broaching of the femoral medullar canal could be easily performed. Followed by implanting a cemented or cement less stem. Results: The median incision length was 6.75 cm. Median angle of cup inclination was 44.1 and 0 of varus/ valgus position for the stem. Blood loss was significantly reduced. The rehabilitation was fast (mean WOMAC score 90.4 at 6 weeks) and patients showed only little postoperative pain. No dislocations or nerve palsies occurred. The complication rate was low with one fissure of the proximal femur, one perforation of the acetabulum and one deep infection. Conclusion: The study demonstrated that blood loss, postoperative pain and hospitalization time were reduced with a correct placement of the implants. The rehabilitation was quicker. Therefore we state that the minimal invasive anterior approach is safe and lead to advantages for the patients

Introduction: Potential benefits cited for minimally invasive total hip arthroplasty (THA) include reduced peri-operative blood loss, less post-operative pain, earlier mobilisation and a shortened hospital stay. Sceptics, however, are concerned about the widespread introduction of a new surgical technique in the absence of objective scientific evidence. The ever-increasing pressure on healthcare budgets by an ageing population makes developments in surgical technique that allow earlier mobilisation and reduced length of hospital stay highly desirable. The aim of this study was to investigate whether a minimally invasive technique in THA would result in a reduced length of hospital stay compared to a standard incision of 16cm. Materials and Methods: 219 patients were randomised to either a minimally invasive (less than or equal to 10cm) or standard (16cm) incision group. Patients were blinded to their incision length. Anaesthetic and post-operative analgesic protocols were standardised. A single surgeon performed all operations using an uncemented cup and a cemented stem. Post-operative physiotherapy was standardised with the physiotherapists also blinded to incision length. Patients were discharged when safely able to transfer and mobilise with a walking aid. Results: There was no statistically significant difference in mean length of stay following surgery. This was 3.65 days (SD 2.04) for the mini-incision group and 3.68 days (SD 2.45) for the standard incision group (p=0.94). 32% of patients (35/110) in the standard incision group were able to go home on day 2 compared to 27% (29/109) in the mini-incision group. Using logistic regression analysis, the patient variables most significantly associated with a probability of discharge within 3 days of surgery were patient age (Wald=33.36, p< 0.0001) and pre-operative haemoglobin (Wald=10.53, p=0.001). 192 patients (88.5%) were discharged to their own homes with the main determinant of discharge to the patients’ own home being the availability of adequate family support. Conclusion: Total hip arthroplasty performed through a single incision minimally invasive approach does not reduce the length of hospital stay compared to THA performed through a standard incision of 16cm

Method: This study reports upon 216 patients (97 Minimally invasive and 119 Standard) enrolled into a randomised control trial comparing a standard posterior approach to the hip with a single incision minimally invasive surgery (MIS) posterior approach at 6 weeks and 1 year post-operatively. Primary outcome measures included operative time, blood loss, length of stay and functional hip scores. Results: The demographics and pre-operative hip scores for both cohorts were statistically similar. Intra-operative blood loss was significantly reduced in the MIS cohort (p=< 0.01). There was no difference in surgical time (p=0.37), time to discharge (p=0.24) or complication rate between the two groups. Both groups had statistically improved post-operative hip scores, however, at the 1 year follow-up the MIS group were significantly better in terms of WOMAC, Harris Hip, Merle d’Aubigne and SF-12 scores when compared with a standard posterior approach. Conclusion: This study demonstrates that MIS THA is a safe, reproducible technique in a DGH. We recommend the use of MIS techniques in primary THA and adhere to the principle that an incision need be no longer than necessary to perform the procedure safely

Objective: To compare the cup and stem position in matched pairs of cadaveric hips performing a minimally invaisve total hip arthroplasty (MIS-THA) either by using manual guidance tools or by the STRYKER Hip-track Navigation System.

Background: Minimally invasive techniques are currently introduced to THA. Our workgroup has developed a direct anterior single incission approach. Special instruments have been designed for retraction and implantation. Instruments are navigable with the STRYKER hiptracksystem. Perfect positioning of the acetabular and femoral component are among the most important factors in THA. Malpositioning may result in significant clinical problems such as dislocation, impingement, limited range of motion or extensive wear.

Design/Methods: In twelve fixated human cadavers hemispherical pressfit cups (TRIDENT, Stryker, Alledale, NJ) and straight femoral components (ACCOLADE, Stryker, Allendale, NJ) were implanted. All implantation were done throught the minimally invasive direct anterior approach. On one side the surgery was performed with spezial MIS instruments. On the oposite side the navigation system was used for placement of the implants. The aim was to achieve an alignment for the cups with 45° of inclination and 15° of anteversion in reference to the frontal pelvic plane. For the stem the goal was to position the stem in 0° of varus/valgus relative to the proximal shaft axes. This plane and the resulting cup positions were measured on CT-scans with a 3D imaging software (Stryker-Leibinger, Freiburg, Germany).

Results: The Innsbruck MIS approach to the hip could be performed in all cases. For both groups cup and stem position where within the range of variation reported in the literature. Yet, variance of the deviation from the goal was higher in the conventional group for both inclination and anteversion with the medians for the navigated group for inclination, anteversion and stem position being closer to the goal then in the conventional group.

Conclusion: The described minimally invasive approach to the hip is feasible and renders results compareable to those reported for conventionally operated THA. By the use of the navigation system tested it is possible to increase placement precission

Repair of distal biceps tendon rupture is a subject that has received increasing attention in the past decade. In the active individual who desires as close to normal function as possible, repair of biceps tendon is recommended. The author describes a tehnique with a single anterior incision and fixation with superanchors. This method was successfully used in 25 patients with excellent functional results. There were no failures and no complications of neurological injury. The single anterior incision approach in which superanchors are used is recommended as an alternative to the traditional two-incision method. The Biceps brachii is an important flexor of the elbow and is the main supinator of the forearm. Avulsion of its distal tendon insertion is rare injury that mostly affects middle-aged men. It represents only 3% of all biceps tendon ruptures. There is an average of 1.24 spontaneous complete distal biceps ruptures per 100,000 people per year. The decline in the number of distal biceps tendon ruptures with increasing age correlates with a decrease in at-risk activities after the fourth decade of life. Decreased vascularity, tendon impingement, degenerative changes of the distal biceps tendon and the use of anabolic steroids have been postulated to predispose to tendon rupture. Our study shows that repair of distal biceps tendon ruptures using superanchors is safe and gives clinically objective and functional results similar to bone tunnel fixation. We had no major complications, no suture anchor failures and no occurrence of synostosis and neurological injuries. We recommend the use of superanchors for the treatment of distal biceps tendon ruptures

The December 2015 Children’s orthopaedics Roundup. 360 . looks at: Paediatric femoral fractures: a single incision nailing?; Lateral condylar fractures: open or percutaneous?; . Forearm refracture: the risks; Tibial spine fractures; The child’s knee in MRI; The mechanics of SUFE; Idiopathic clubfoot

Previous studies describing drill trajectory for single incision distal biceps tendon repair suggest aiming ulnar and distal (Lo et al). This suggests that the starting point of the drill would be anterior and radial to the anatomic insertion of the distal biceps tendon. Restoration of the anatomic footprint may be important for restoration of normal strength, especially as full supination is approached. To determine the safest drill trajectory for preventing injury to the posterior interosseous nerve (PIN) when repairing the distal biceps tendon to the ANATOMIC footprint through a single-incision anterior approach utilising cortical button fixation. Through an anterior approach in ten cadaveric specimens, three drill holes were made in the radial tuberosity from the centre of the anatomic footprint with the forearm fully supinated. Holes were made in a 30º distal, transverse and 30º proximal direction. Each hole was made by angling the trajectory from an anterior to posterior and ulnar to radial direction leaving adequate bone on the ulnar side to accommodate an eight-millimetre tunnel. Proximity of each drill trajectory to the PIN was determined by making a second incision on the dorsum of the proximal forearm. A K-wire was passed through each hole and the distance between the PIN and K-wire measured for each trajectory. The PIN was closest to the trajectory K-wires drilled 30° distally (mean distance 5.4 mm), contacting the K-wire in three cases. The transverse drill trajectory resulted in contact with the PIN in one case (mean distance 7.6 mm). The proximal drill trajectory appeared safest with no PIN contact (mean distance 13.3 mm). This was statistically significant with a Friedman statistic of 15.05 (p value of 0.00054). When drilling from the anatomic footprint of the distal biceps tendon the PIN is furthest from a drill trajectory aimed proximally. The drill is aimed radially to minimise blowing out the ulnar cortex of the radius. For any reader inquiries, please contact . vansurgdoc@gmail.com

Distal biceps tendon ruptures are uncommon with a reported incidence of 1.24 per 100,000 per year. They typically occur in males in the fourth decade. Operative treatment has been shown to improve functional outcomes in the treatment of distal biceps tendon ruptures. A variety of surgical techniques have been described, usually using the dual incision Boyd-Anderson approach. We report a series of 10 patients with 10 tendon ruptures treated using a single incision volar approach and using the Arthrex Biotenodesis screw to reattach the tendon to the radial tuberosity. This method has been previously described in only one case report. All ten patients underwent clinical assessment using the Mayo Elbow Performance Score (MEPS) and functional assessment using the DASH scoring system. The power was assessed isokinetically using the Nottingham Myometer. Based on the MEPS and DASH grading system all patients achieved a good or excellent result. In our experience reattachment of the distal biceps tendon using a single incision approach and Arthrex Biotenodesis screw is a new technique which gives a good functional outcome

Introduction: It has been stated that less invasive total hip arthroplasty requires patient selection to lessen complications and to promote a successful outcome. However, it is unknown if certain patients risk an increase in complications, or if unselected patients benefit from these operations. This prospective study addresses these questions. Methods: Two patient groups, from a larger series, were studied: BMI over 30 (71 patients); Age over 80 (41 patients). The average BMI was 34 (highest 46); the average age, 84 (oldest 91). A single incision direct anterior approach was used universally. At regular follow-up WOMAC, Charnley modified Merle D’Aubigne, Harris Hip Scores and x-rays were obtained. RESULT: Hip Scores showed significant improvement (p = 0.001 for each), component positioning was reproducible; length of hospital stay and return to full function were acceptable. However, compared to non-obese, younger patients having the same operation, the very elderly were less likely to go directly home (45% compared to 80% overall), the risk of medical complications was increased for these patients (4% of the obese and 6% of the elderly); and there was a disproportionately high incidence of mechanical complications (6% for the obese; 2.5% for the elderly). Discussion: These data indicate that lesser invasive hip arthroplasty using a single incision anterior approach can benefit obese and elderly patients. However, the incidence of complications may be elevated. Information derived from a selected MIS series should be considered sceptically before applying it to our practices

Purpose of the study: Grafting the anterior cruciate ligament with a bone-tendon-bone free transplant injures the harvesting site, causing sensorial disorders by injuring the infrapatellar nerve in 70% of the cases. Mini-invasive techniques can limit these complications. The purpose of this work was to analyse the feasibility of a mini-invasive technique using a single incision. Material and methods: A prospective comparative study was conducted in our unit to compare a group of “classical” harvesting via an anteromedial incision and a “mini-invasive” technique using a incision centred on the patella with the graft being harvested with a specially designed harvesting instrument. Each group was composed of 20 patients. The patients were reviewed six to eight months postoperatively. Clinical assessment (IKDC, Lillois score, analysis of sensorial impairment) was associated with the radiographic and ultrasound analysis. Radiographic laxity was assessed on the stress views at 15 kg. The ultrasound study analysed the patellar tendon and the peritendon. Significance for statistical tests was set at 0.05 with correlation coefficients (R) determined with a covariance matrix ½ Log([1 + R]/[1−R]). Results: The grafts harvested by the classical method presented good characteristics in all cases whereas this was true for only 45% of the mini-invasive grafts. Anterior pain was noted in 22% of patients in the classical group and in 33 of the mini-invasive group. There was no correlation between anterior knee pain and knee walking or thickness of the peritendon. A correlation was found between knee walking and asymmetry of the patellar tendon thickness in the mini-invasive group. The subjective IKDC score was the same in the two groups and the IKDC objective score was not significantly different (94% (A or B) in the classic group and 81% (A or B) in the mini-invasive group. Conclusion: This mini-invasive technique with a single incision respects the infrapatellar branches of the medial saphenous nerve in 95% of the cases. But the quality of the graft is less satisfactory than with the classical harvesting technique. A correlation was found between the form of the anterior tibial tubercle which could be used to better define the ideal indication for this technique which remains a difficult procedure

To review the medium term results of acute repair of rupture of the biceps brachii insertion using a single incision bone anchor anatomical repair. Three patients with acute biceps brachii tendon insertion ruptures and treated surgically using a single incision bone anchor anatomical repair underwent dynamometer strength assessment of both arms using a KinCom isokinetic dynamometer. This was performed shortly after completion of rehabilitation (7–12 months after surgery) and again at 3.3 years after surgery. All patients were male (mean age 40.3 years, range 34 to 53). Surgery was performed less than 7 days post injury using the same technique. Isokinetic assessment was performed at a mean of 8.7 months post surgery (range 7 to 12 months) and again at assessment (maintained at medium term assessment). All patients had returned to their full premorbid occupation and level of sporting activity. Dynamometer results of a repaired dominant limb equated to approximately the strength of a normal non dominant limb, a repaired non dominant side equated to two thirds the strength of a normal dominant limb at early assessment. This relationship was maintained at the medium term assessment, however there was a substantial increase in strength in both affected and unaffected arms. The one incision approach, using bone anchors, is recommended as the method of choice providing an optimal surgical repair with a reduction in the risk factors theoretically associated with anatomical surgical repair. Our short-term results are comparable with other quantitative results published (for both bone anchor and non-bone anchor procedure). The medium term results how a measurable increase in strength of the repaired limb although the strength relative to the uninjured side remains the same as at early assessment

Arthroscopic controlled retrograde drilling of femoral and tibial sockets and tunnels using a specially designed cannulated drill pin and retrocutter (Arthrex Inc, Naples FL.) provides greater flexibility for anatomical graft placement and in revision cases avoids previous tunnels and intra osseus hardware. Inside out drilling of femoral and tibial sockets minimises incisions and eliminates intra articular cortical bone fragmentation of tunnels rims common to conventional antegrade methods. This technique is also ideal for skeletally immature patients since drilling and graft fixation through growth plates may be avoided. Initial tunnel-referencing cannulated drill guide pin placement is carried out from outside-in. This technique (out-in/in-out) combines the advantages of the two-incision and the one-incision technique. In fact it permits us, as in the two-incision technique, to drill a pin guide from outside to inside in order to obtain the correct anatomical insertion of the ACL, otherwise not reproducible from inside-out. Since November 2004 our preferred technique for hamstring (autogenous quadrupled semitendinosis/ gracilis) ACL reconstruction incorporates the above mentioned femoral socket creation. In recent years, arthroscopically assisted ACL reconstruction has become the procedure of choice. Initially, arthroscopic techniques required two incisions for outside-in drilling of bone tunnels, but there has been a trend toward using a single incision with inside-out of the femoral tunnel. Those who advocate the two-incision technique state that they do so primarily because they believe that the two-incision procedures makes accurate femoral tunnel placement easier. Harner found no difference in tunnel placement using the two techniques, while Schiavone found that the inside-out femoral tunnels were significantly more vertical in the one-incision procedure. We have performed two-incision ACL reconstruction routinely since 1977, with very favourable results. The recent variation in our technique affords a reduction in morbidity, associated with improved cosmesis and quicker post-operative recovery. One factor related to our success appears to be a more anatomically positioned femoral tunnel, which in our hands, is difficult to accomplish with the single incision trans-tibial femoral socket creation. The retro-drill technique allows preparation of the correct anatomical femoral and tibial socket or tunnel, either with a very small lateral skin incision or without any skin incisions if the surgeon is using an allograft, and appears to represent a promising future technique in ACL reconstruction

A randomised controlled trial involving 24 patients ( 32 wrists ), 18 wrists being allocated to the single incision group ( S ) and 14 to the double incision group ( D ), was carried out between 1996 and 1999, after clinical evaluation and complimentary EMG studies. Randomisation was performed by one of the orthopaedic secretaries using an envelope technique on the morning of admission. Mean ages were 49.6 ( 32 to 69 ) and 45.8 ( 30 to 54 ) in the S and D groups respectively. The male to female ratios were 2/12 and 5/7 respectively. The pre- and post-operative mass grip strength was measured by a Jamar dynanometer and assessment of post-operative parameters included pillar pain, scar sensitivity, nerve compression symptoms and return to work. Pillar pain was significantly less in Group D ( Chi-squared = 8.22; P = 0.004 ). Return to work was less in Group D ( average = 2.6 weeks ( 1 to 12 weeks )) cf. to Group S ( average = 5.6 weeks ( 2 to 16 weeks ) ). ( Wilcoxon Rank Sum Test P = 0.0004 ). No differences occurred in post-operative clinical symptoms ( P > 0.05 ), scar sensitivity ( Chi-squared = 1.025 ; P = 0.506 ) or mass grip strength ( P= 0.506 ). The tourniquet time was longer for the double incision technique ( average = 15.3 minutes ( 12 to 18 minutes )) cf. to the single incision technique ( average = 12.2 minutes ( average = 10 to 18 minutes )). The double incision technique is a safe and easy technique for uncomplicated carpal tunnel syndrome resulting in a significant reduction in pillar pain and a more rapid return to work

Background. Robotic assistance is being increasingly utilised in the surgical field in an effort to minimise human error. In this study, we report minimum two-year outcomes and complications for robotic-assisted total hip arthroplasty. Methods. Data were prospectively collected and retrospectively reviewed between June 2011 and April 2014. Inclusion criteria were primary robotic-assisted THAs treating idiopathic osteoarthritis with ≥ 2- year follow-up. Demographics, operating time, complications, 2-year outcome scores and satisfaction, and subsequent surgeries were recorded. Results. There were 181 cases eligible for inclusion, of which 162 (89.5%) had minimum 2-year follow- up. Eighty-nine females and 73 males were included. Forty-seven cases used an anterior approach and 115 used posterior approach. Mean age was 61.2 and mean BMI was 29.8. At latest follow-up, mean Visual Analog Scale for pain was 0.7, patient satisfaction was 9.3, Harris Hip Score was 91.1, and Forgotten Joint Score was 83.1. The mean time of surgery was 76.7 min. There were three (1.9%) greater trochanteric fractures and three (1.9%) calcar fractures. Postoperative complications included deep vein thrombosis (2 cases, 1.2%), femoral stem loosening (one case, 0.6%, treated with stem revision), infection (1 case, 0.6%, treated with single stage incision and drainage), aseptic hematoma (1 case, 0.6%, treated with single stage incision and drainage), and dropfoot (1 case, 0.6%). No leg length discrepancies (LLD) or dislocations were reported. Conclusion. Robotic-assisted THA is a safe procedure with favorable short-term outcomes. In particular, the excellent Forgotten Joint Score results suggest that this procedure effectively replicates the feeling of the native hip

Introduction. We describe a novel single incision approach and its safety in the largest reported series of Lisfranc injuries to date. Via separate subcutaneous windows it is possible to access the medial three rays of the foot for bridge plating, without the concern of narrow skin bridges between multiple incisions. Methods. A retrospective review identified all 150 patients who underwent a Lisfranc ORIF via the modified dorsal approach at the Royal Melbourne Hospital between January 2011 and June 2016. All patients were operated by a single surgeon. Removal of metalwork (ROM) was routinely undertaken at six months post-operatively via the same incision. Medical recored were reviewed to record patient demographics, mechanism of injury and surgical details. Outpatient notes were reviewed to identify wound-related complications including; delayed wound healing, superficial infection, wound dehiscence, deep infection, complex regional pain syndrome (CRPS), neuroma and impaired sensation. Median follow-up was 1012 days (range 188–2141). Results. Median age was 37 years (19–78). 110 (73%) patients were male. Mechanism of injury was: motor vehicle accident (37%), motor bike accident (19%) and fall (18%). 24 (16%) injuries were open, 5 of which required soft tissue reconstruction at the primary surgery. A total of 34 wound related complications occurred (22%); superficial infection (14), delayed wound healing (7), wound dehiscence (5), CRPS (4), impaired sensation (3), neuroma (1). Re-operation was necessary in the 5 patients who experienced wound dehiscence; 4 requiring split skin grafts and 1 requiring a free flap. Crush injuries were 10 times more likely to have wound complications than those sustained in motor vehicle accidents. Patients undergoing ROM were more likely to have wound complications than those who did not. Conclusion. The modified dorsal approach using subcutaneous windows to access the midfoot joints offers a viable alternative to existing approaches

Introduction. Fixation of posterior malleolar fragments associated with ankle fractures aims to stabilise the syndesmosis and prevent posterior subluxation. Haraguchi described 3 types of posterior malleolar fractures, with type 2 being a medial extension injury, these fractures often involve medial and posterior fragments. We describe the techniques and outcomes for a double window posteromedial approach allowing optimal reduction and stabilisation. Methods. A retrospective review was performed at 2 units, Bristol Royal Infirmary and QE Hospitals Birmingham, between August 2014 and April 2016. Inclusion criteria were all patients having this posteromedial approach for closed ankle fracture fixation. Patients were assessed for complications and postoperative ankle function with the Olerud and Molander scoring system. Results. We identified 9 patients treated over an 18 months with average follow up 9 months (range 4–18 months). All had an ankle dislocation reduced on scene or in ED, with 5 having posterior subluxation of the talus on the original films. None were open injuries. All had fixation of a posteromedial malleolar fragment, with 7 requiring a further direct lateral incision. Olerud and Molander ankle function score averaged at 72 (range 60–85) at short term follow up. Discussion. Approaches to the posteromedial fragments have been previously described in 2 ways. One utilises a window just medial to the Achilles tendon taking the neurovascular bundle medially, while the other approaches between tibialis posterior and FDL taking the neurovascular bundle laterally. Neither delivers complete access to an injury that often has sagittal and coronal splits needing individual reduction and fixation. Our approach over the neurovascular bundle allows 2 safe corridors through a single incision facilitating fragment specific fixation of both the medial and posterior components of the injury. Early results suggest this to be a safe and reliable technique to reduce and stabilise complex posteromedial ankle fractures

Knee arthrodesis is a useful procedure in difficult cases such as failed total knee arthroplasty, bone tumors and infected knee joints. A review of 27 cases treated using a modular locked intramedullary nail “Wichita” in 4 hospitals was performed. This fusion nail is a device designed to provide simultaneous compression and intramedullary fixation. The device is implanted through a single knee incision using three main components after femoral and tibial reaming. The femoral components inserts retrograde and has two holes in its proximal end to accept transverse locking screws. The tibial component inserts anterograde into the proximal tibia and has some holes for transverse screw placement. The compression screw component is used to lock the femoral and tibial components together and simultaneusly compression is generated across the joint line. Teorical advantages are single incision, inmediate and solid stability, posibility of compression, adjust of length, high fusion rates and less risk of infection than other procedures. An individual study protocol was made and it includes previous primary or revision failed total knee replacement, severe articular trauma and infection. No bone tumors were includes. Protocol includes aspects such as operative time and blood loss,intraoperative complications, radiographic evaluation (tibiofemoral alignement, contact tibiofemoral surface area...) shortenning of extremity, time to union, posoperative complications and patient subjective evaluation.10 patients are being studied prospectively in our institution since january 2000 and the mean follow-up is 16 months. 17 patients were retrospectively studied in 3 differents hospitals using the same protocol and the mean follow-up is 26 months. Global results show a solid fusion in 26 (96 per cent) of the 27 patients at an average time of 15 weeks (range 12 to 22 weeks) after the operation. There were one mechanical failure of the implant (thecnical mistake during assembly of the compression screw component). There were 2 non desplaced fractures in the end of the nail. There was 1 desplaced fracture and removed of implant was required, osteosynthesis was performed with a long intramedullary nail. No infections were detected. These results and others are related. Although good results observed, with high fusion rates and minimal complications, a potential disadvantage is the difficult to remove the nail if this is necesary

Developmental dysplasia of the hip (DDH) is relatively a common condition that can lead to early arthritis of the hip. Although total hip arthroplasty is the surgical treatment of choice for these patients with end stage arthritis, some patients afflicted with DDH may present early. Acetabular osteotomy, in particular Bernese or periacetabular osteotomy (PAO as described by Professor Ganz and Jeff Mast back in 1980s) may be an option with patients with symptomatic DDH who have joint space available. PAO has many advantages. First, it is performed through a single incision (modified Smith Peterson approach) without breaching the abductor mechanism. The periacetabular fragment has, hence, excellent blood supply and avascular necrosis of the acetabular portion is not an issue. In addition, the osteotomy is so versatile allowing for great mobility of the fragment to obtain coverage even in the worst of circumstances. The osteotomy does not affect the posterior column and hence allows for earlier weight bearing. Most joint preservation surgeons in North America and Europe prefer PAO to other types of osteotomy. The indications for PAO are a patient with symptomatic DDH who has good joint space and a congruent joint. The congruency of the joint is usually determined by the abduction views (obtained at 30 degrees abduction and neutral rotation). Although the joint space may be measured on plain radiographs, in recent years some centers have been utilising cross sectional imaging, such as dGEMERIC for evaluation of the articular cartilage, which has been shown to be a good predictor of outcome for PAO